Identification Number :

 

 

   Demographics

  
This section to be filled out the first time you submit this questionnaire. Subsequent submissions do not require entering demographic information.
Demographics of school(s) for which you are a nurse:
  A. Grade level and distance to nearest emergency room. (check all that apply)
Name of School:
Grade Level:
K 1 2 3 4 5 6
7 8 9 10 11 12		 Distance to Nearest
Emergency Room: (miles)
0-5 6-20 21-50 51-100 Unknown
Name of School:
Grade Level:
K 1 2 3 4 5 6
7 8 9 10 11 12		 Distance to Nearest
Emergency Room: (miles)
0-5 6-20 21-50 51-100 Unknown
Name of School:
Grade Level:
K 1 2 3 45 6
7 8 9 10 11 12		 Distance to Nearest
Emergency Room: (miles)
0-5 6-20 21-50 51-100 Unknown
        
   B. Your level of training: (check all that apply)
 
LPN   RN   RN,C   BSN   MA   MSN   PALS   ENPC   SNEMS
 

The School Nurse and Emergency Medical Services in New Mexico
SURVEY
This section to be filled out each time a student or staff is sent out of school for urgent or emergency care by you or anyone. Please provide the following information:
Date of incident:
(enter mm/dd/yy, i.e. 10/08/03)		 Time of incident:
(enter hh:mm, i.e. 05:35)		 AM
PM		 Name of school:

1.) What was the category of the incident?
Medical problem Respiratory-asthma GI or GU Musculoskeletal
ENT or dental Respiratory-other Trauma Other:
Shock
 		 Multiple casualty
 		 Psycho behavioral
 		  
2.) Who was the emergency for? (check all that apply)
Student          Staff            Other
Age: (years)          Gender: M     F
3.) To what extent was the school nurse involved in this incident? (check all that apply)
Not involved          Involved by telephone            On the scene
4.) Did the emergency require transport out of the school?
Yes        No       
5.) If transport was required, who transported?
By parent/guardian      By school nurse      By other school employee

By ambulance                Self-transported
6.) If transport was required, what was the transport destination?
To clinic or doctor's office      To Emergency Room     Other:
7.) Was an ambulance called?
Yes        No       
 If an ambulance was called for emergency transport, please answer the following:
8.) Title of person (no name) who made the decision to call the ambulance:
Nurse      Principal      Clerical      Custodial     Teacher

Student   Parent/guardian            Other
 
9.) What time was it called?    (enter hh:mm, i.e. 05:35)     
10.) What was the approximate response time? (enter only minutes i.e. 15, 35, 70, etc)
11.) What were the Interventions prior to EMS arrival? (check all that apply)
Oxygen             Nebulizer          Metered dose inhaler         

Backboard       Splint                C-spine stabilized          
 
 Other:
 
12.) What were the Interventions done by EMS? (check all that apply)
Oxygen             Nebulizer           Metered dose inhaler          I.V. Medication

Backboard       Splint                  C-spine stabilized               Unknown
 
 Other:
 
 

Please click on the SUBMIT button below
to enter the results of your survey
 

       

 

Grant funded by EMS-C #5H34 MC00107-03